Get Az Medical Board Complaint Form 2017

Filing a complaint with the Arizona Medical Board is a crucial step for individuals who wish to report concerns about an allopathic physician. This guide will walk you through the process of completing the AZ Medical Board Complaint Form online, ensuring your submission is clear and effective.

Follow the steps to successfully complete the complaint form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the section for the person filing the complaint. Provide your full name, mailing address, city, state, zip code, phone number for contact during business hours, and email address. Make sure to enter accurate information to facilitate communication.
3. Next, provide the patient's information. Enter the name of the patient and their date of birth if you are not the patient yourself. If applicable, clearly state your relationship to the patient.
4. In the section indicating the complaint against the physician, fill in the full name of the M.D. and their office address, including street address, city, state, and zip code.
5. Specify the date(s) of the incident that prompted the complaint.
6. Provide a summary of your allegations. Clearly outline who was involved, what occurred, when it happened, and where it took place. Use bullet points for clarity and ensure your writing is legible.
7. If applicable, complete the treatment information form on the next page regarding other healthcare providers involved. Specify the primary care physician, any referrals made, and details of treatment received.
8. Indicate whether you possess any x-rays related to the complaint and provide information about where they were taken.
9. Before submitting, review all sections of the form for accuracy. Once satisfied, you may proceed to save your changes, download, print, or share the completed form.

Take action today by filing your complaint online for a thorough review.